Esophageal Balloon Insertion in a Medical-Surgical Intensive Care Unit: Patient Characteristics and Consequences
CCCF ePoster library. Piraino T. Nov 2, 2016; 151010
Thomas Piraino
Thomas Piraino
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Topic: Clinical Case Report

Esophageal Balloon Insertion in a Medical-Surgical Intensive Care Unit: Patient Characteristics and Consequences


Piraino T, Clarke FJ, Shears M, Soth M, Ligori T, Cook D.  McMaster University, Hamilton, Canada and St. Joseph’s Healthcare, Hamilton, Canada



Abstract:

Background: Pleural pressures are unpredictable in patients with Adult Respiratory Distress Syndrome (ARDS) and other individuals due to obesity, fluid overload and high abdominal pressures. Better understanding of pleural pressures could have a significant role in appropriate ventilator settings in the ICU.

Objective: To evaluate the patient characteristics and consequences of transpulmonary pressure (Ptp) measurements with an esophageal balloon in critically ill patients.

Design: Retrospective chart review from May 2010 to September 2013.

Setting: 21 bed medical-surgical ICU in Hamilton, Canada.

Methods: We included consecutive patients age >18 years if they were mechanically ventilated and had a Ptp measurement performed. We collected baseline demographics, ARDS risk factors, ventilator settings, medications (inotropes, neuromuscular blocking agents [NMBA]), barotrauma and outcomes at ICU and hospital discharge.

Results: Of 61 patients (mean APACHE II score of 24.7), the primary ICU admission diagnosis was bacterial/viral pneumonia (n=22, 36.1%), followed by sepsis (n=10, 16.4%), and cardiac arrest (n=6, 9.8%). Overall, 44 of 61 (72.1%) patients had at least 1 of 8 ARDS risk factors. Prior to esophageal balloon insertion, 51.2% of patients had a CXR compatible with ARDS. Most patients (91.7%) were receiving pressure control ventilation at the time of insertion and the mean duration of mechanical ventilation prior to esophageal balloon insertion (pre Ptp) was 4.5 days. The mean Positive End Expiratory Pressure (PEEP) pre Ptp was 15.8 cmH20, which increased to 18.6 cmH20 4 hours post Ptp (p <0.05), and 17.4 cmH20 at 72 hours post Ptp (p =0.2). Following balloon insertion, 43 patients (71.7%) had an increase in PEEP, 7 patients (11.7%) had a decrease in PEEP by a mean of 6 cmH20, and 10 patients (16.7%) had no change in PEEP. Mean airway pressure was a mean of 22.4 cmH20 at baseline, 26.1 cmH20 at 4 hours post, and 23.2 cmH20 at 72 hours post Ptp. The mean p/f ratio was 112 pre Ptp, 151 at 2-4 hours post Ptp (p =0.08), and 202 at 72 hours post Ptp (p <0.05).  Inotropic agents were used for 31 patients (50.8%) pre Ptp vs 29 (47.5%) post Ptp; NMBA were used in 22 (36.1%) pre Ptp vs 23 (37.7%) post Ptp. Mean compliance was 24.4 ml/cmH20 at baseline, 22.6 ml/cmH20 at 4 hours post, and 28.1 ml/cmH20 at 72 hours post esophageal balloon insertion. Most esophageal balloons were inserted on day shifts (73.8%). Of 61 patients, 3 (4.9%) had a pneumothorax within 2 days following balloon insertion (1 patient had PEEP decreased, 1 patient had PEEP increased and a thoracentesis, 1 patient had PEEP decreased and a central line insertion). The average total duration of mechanical ventilation was 20.2 days; 28 patients died in ICU (46.0% mortality).  Of the 28 patients who died in the ICU, 27 underwent withdrawal of life support.

Conclusion:  Esophageal balloon measurement was implemented for these medical-surgical ICU patients, half of whom had conditions other than ARDS.   Balloon insertion was not associated with any changes in the need for inotropic support or NMBA, and was usually followed by an increase in PEEP, and consequent increase in P/F ratio.


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